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Consensus Document on Treatment of Infections in Diabetic Foot

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Consensus Document on Treatment of Infections in Diabetic Foot Consensus document Blanes Mompo JI and represen- tatives of the Spanish Society Consensus document on treatment of of Surgeons (ACS); Spanish So- ciety of Angiology and Vascular infections in diabetic foot Surgery (SEACV); Spanish So- ciety of Emergency Medicine (SEMES); Spanish Internal Me- dicine Society (SEMI); Spanish Society of Critical Care Medici- ne and Coronary Units (SEMIC- Coordinators: Francisco Lozano and Albert Clará (SEACV). Members of ad hoc committee: Diego Alcalá (AEC); Albert Clará, José Ignacio YUC), and Spanish Society of Blanes, Esther Doiz, Rocío Merino, Francisco Lozano (SEACV); Juan González del Castillo (SEMES); José Barberán (SEMI); Rafael Chemotherapy (SEQ). Zaragoza (SEMICYUC); and José Elías García Sánchez (SEQ). ABSTRACT Documento de consenso sobre el tratamiento de las infecciones en el pie del diabético Diabetic foot infection, particularly if it is associated to is- chaemia, is the most common cause of lower limb amputation, in RESUMEN the general population, of hospital admissions, and a decrease in the quality of life in diabetics. Of all diabetics, 15% of them are La infección del pie diabético, sobre todo si se asocia a going to suffer from a foot infection during their life, with an an- isquemia, es la causa más frecuente de amputación de extremi- nual incidence of 1-4%, preceded by a foot ulcer in more than dad inferior en la población general y de ingreso hospitalario y 80% of cases. They are complex infections and the prognosis is disminución de la calidad de vida en los diabéticos. EL 15% de los influenced by many factors, depending on the ulcer (location, ex- diabéticos van a sufrir a lo largo de su vida una infección del pie, tension, whether chronic or not, previous amputation, ischaemia con una incidencia anual del 1-4%, precedida en más del 80% de grade), and the patient (age, renal impairment, time of onset of los casos de una úlcera en el pie. Son infecciones complejas en diabetes, associated comorbidity). All these must be taken into cuyo pronóstico influyen muchos factores, dependientes de la úl- account when establishing its treatment. cera (localización, extensión, cronicidad, amputación previa, gra- The infections must be classified according to their severity do de isquemia) y del paciente (edad, insuficiencia renal, tiempo (mild, moderate-mild, moderatesevere, and severe). Their treat- de evolución de la diabetes, comorbilidad asociada), lo que hay ment is complex and must be multidisciplinary and must include que tener en cuenta a la hora de plantear su tratamiento. Las in- debridement, discharge, adequate antibiotic therapy, revasculari- fecciones deben clasificarse en función de su gravedad (leves, sation, and treatment of the ulcer. moderadas-leves, moderadas-graves y graves). Su tratamiento es In this consensus document, produced in collaboration with complejo y debe ser multidisciplinar. Debe incluir desbridamiento, the Spanish Angiology and Vascular Surgery Society (SEACV), the descarga, antibioticoterapia adecuada, revascularización y cura Spanish Society of Internal Medicine (SEMI), the Spanish de la úlcera. Chemotherapy Society (SEQ), the Spanish Surgeons Association En este documento de consenso, fruto de la colaboración de (AEC), the Spanish Society of Urgent Medicine and Emergencies la Sociedad Española de Angiología y Cirugía Vascular (SEACV), (INFURG-SEMES) and the Spanish Society of Intensive and Criti- Sociedad Española de Medicina Interna (SEMI), Sociedad Españo- cal Medicine and Coronary Care (SEMICYUC), the guidelines are la de Quimioterapia (SEQ), Asociación Española de Cirujanos developed based on the best available evidence on diabetic foot (AEC), Sociedad Española de Medicina de Urgencias y Emergen- infections, aimed at achieving greater clinical efficacy. cias (INFURG-SEMES) y Sociedad Española de Medicina Intensiva, Key Words: Diabetic Foot, Diabetic Foot Ulcer, Diabetic Foot Infection, Antibi- Crítica y Unidades Coronarias (SEMICYUC), se desarrollan las pau- otics tas, basadas en la mejor evidencia disponible, de las infecciones de pie diabético, encaminadas a obtener la mayor eficacia clínica Palabras Clave: Pie diabético, Ulcera pie diabético, Infección pie diabético, an- tibióticos RATIONALE Correspondence: Jose Ignacio Blanes Mompó E-mail: [email protected] Diabetes is a health problem of the first order, as shown by its high prevalence and numerous consequences. One of the most common complications during the life of a diabetic is the development of an ulcer in the foot. An important European 73 Rev Esp Quimioter 2011;24 (4): 233-262 233 J.I. Blanes, et al. Consensus document on treatment of infections in diabetic foot study1 states that half of these ulcers are associated with is- chemia (49%) or infection (58%), or the combination of both in HYPERGLYCEMIA one third of cases (31%). This aggravates the condition, increas- ing in the rate of amputations and mortality in these patients. NORMAL FOOT Conscious of the problem of diabetic foot (DF), the Spanish PREDISPOSING FACTORS Society of Angiology and Vascular Surgery (SEACV), commis- sioned in 1996 an “ad hoc” committee to develop a consensus on consensus on DF2. Years later (2005), the SEACV, based on the FOOT AT RISK OF LESIONS importance for the specialty of all aspects related to DF, created the specific DF group, now Section, called Pie Diabético - SEACV3. TRIGGERING FACTORS Only one year later, members of the SEACV and of that Section were asked to be part of an expert panel, on behalf of several medical societies, to develop a consensus document on the an- ULCER / LESION timicrobial treatment of DF infections, where they have provided treatment regimens based on the best available evidence for AGGRAVATING FACTORS achieving the greatest clinical efficacy4. The treatment of infec- tions of the DF, of great complexity, requires multidisciplinary care because of the multiple factors involved in its development5. CRITICAL INJURY (Limb prognosis) This document is primarily designed to give continuity to and update the previously mentioned consensuses. The level and Figure 1 General pathophysiology of diabetic quality of clinical evidence is not the most desirable due to the foot ulcer. lack of homogeneity of the available information (clinical trials), so many of the decisions presented are based on expert opinion. patients17,18. After amputation of a lower limb, the incidence of EPIDEMIOLOGY a new ulcer, and/or contralateral amputation at 2-5 years is 50%11,19. Survival of diabetic patients undergoing amputations Diabetes is a highly prevalent disease (6% of the popula- is significantly worse than the rest of the population and even tion), with a similar proportion of undiagnosed patients who less if they have experienced another prior amputation11. Only have the disease, which has multiplied by 6 the number of dia- 50% to 40% of patients survive 3 and 5 years from an ampu- betics in the past 40 years6. In addition, there is an increase tation, respectively, and prognosis worsens as the level where with age, reaching 11% in the persons over 657. In developed it is performed increases19,20. countries, it is the 7th cause of death as a direct cause, with- Although the costs derived from DF ulcers and other in- out taking into account its role in cardiovascular mortality, the fections are not accurately known, in the U.S. it is estimated 7-9 leading cause of early death in diabetics . that an ulcer episode costs from $4,500 to $28,000 at two Diabetic patients, as a consequence of their extended life years after diagnosis, with a mean of $5,500 per patient per expectancy, have many problems, including DF. The main late year21,22. Although mean hospital stay of an amputation has complications of diabetes (atherosclerosis, neuropathy, decreased, it remains a costly procedure, ranging from $20,000 retinopathy, etc.) are vascular (macro and microangiopathy) to $40,000 depending on the level of amputation, hospital and metabolic in their pathogenesis. Foot ulcer is one of the stay, or patient comorbidities11,23. More up-to-date and simi- most common complications in the lower extremities of dia- larly high values are available for Europe24. betics. It appears during the course of disease in approximately Finally, we should mention that recent Spanish epidemio- 10-12 15% of cases . Its annual incidence is 2-3% and 7% in pa- logical studies are available25,26 which report along the same 13,14 tients with neuropathy, and its prevalence is 2-10% . lines (prevalence, frequency of amputation, mortality, etc). Foot infections affecting the skin and soft tissues, and bone, with or without systemic impact, are the most common PATHOPHYSIOLOGY reason for hospitalization of diabetics (25%), with prolonged 11 stays . Understanding of the pathophysiology of DF is essential Diabetes is the most common cause of lower extremity for optimal care, since modifying the factors that influence its amputation in Europe and the U.S.15. The annual rate of ampu- development can restore or keep the foot intact, conserving tations adjusted for age is 82 per 10,000 diabetics. These pa- the limb and maintaining a healthy foot so that the patient tients have a 15 to 40-fold greater risk of requiring an ampu- can lead a completely normal life. Although DF lesions may tation than the nondiabetics and men at least 50% more than seem different, the path leading to a foot ulcer and its compli- women8,16. Diabetics with a foot ulcer will require an amputa- cations is very similar, and is determined by various factors. tion
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